The General US Politics Thread

Nobody knew it in January, but within months, the new coronavirus would sweep the United States, killing tens of thousands of people, a disproportionately high number of them black and diabetic. They were at a disadvantage, put at risk by an array of factors, from unequal health care access to racist biases to cuts in public health funding. These elements have long driven disparities, particularly across the South. One of the clearest ways to see them is by tracking who suffers diabetic amputations, which are, by one measure, the most preventable surgery in the country.

Look closely enough, and those seemingly intractable barriers are made up of crucial decisions, which layer onto one another: A panel of experts decides not to endorse screening for vascular disease in the legs; so the law allows insurance providers not to cover the tests. The federal government forgives the student loans of some doctors in underserved areas, but not certain specialists; so the physicians most critical to treating diabetic complications are in short supply. Policies written by hospitals, insurers and the government don't require surgeons to consider limb-saving options before applying a blade; amputations increase, particularly among the poor.

Despite the great scientific strides in diabetes care, the rate of amputations across the country grew by 50% between 2009 and 2015. Diabetics undergo 130,000 amputations each year, often in low-income and underinsured neighborhoods. Black patients lose limbs at a rate triple that of others. It is the cardinal sin of the American health system in a single surgery: save on preventive care, pay big on the backend, and let the chronically sick and underprivileged feel the extreme consequences.

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Fakorede spent four days driving through its long, flat stretches of farmland dotted with small towns and shotgun houses. The wood-slat homes and bumpy roads reminded him of his grandparents' village in the Nigerian state of Ondo, where he'd spent summers as a kid. He drove scores of miles on the Mississippi highways without seeing a single grocery store; fast-food chains lit the busiest intersections. He was startled by the markers of disease - the missing limbs and rolling wheelchairs, the hand-built plywood ramps with metal rails. He thought of amputees like "an hourglass," he said, "that was turned the day they had their amputation." Mortality rates rise after the surgeries, in part, because many stop walking. Exercise improves circulation and controls blood sugar and weight. The less activity a person does, the higher the risk of heart attacks and strokes. Within five years, these patients were likely to be dead.

Fakorede weighed taking a lucrative job up north, near his parents, who had both been diagnosed with diabetes. He had professional connections there; he'd gone to Rutgers Robert Wood Johnson Medical School and done a residency at NewYork-Presbyterian Weill Cornell Medical Center. But the South, he felt, needed him. About 30 million people in America had diabetes, and Mississippi had some of the highest rates. The vast majority had Type 2; their bodies resisted insulin or their pancreas didn't produce enough, making their blood sugar levels rise. Genetics played a role in the condition, but so did obesity and nutrition access: high-fat meals, sugary foods and not enough fiber, along with little exercise. Poverty can double the odds of developing diabetes, and it also dictates the chances of an amputation. One major study mapped diabetic amputations across California, and it found that the lowest-income neighborhoods had amputation rates 10 times higher than the richest.

The Delta was Mississippi's poorest region, with the worst health outcomes. Fakorede had spent years studying health disparities: African Americans develop chronic diseases a decade earlier than their white counterparts; they are twice as likely to die from diabetes; they live, on average, three years fewer. In the Delta, Fakorede could treat patients who looked like him; he could find only one other black interventional cardiologist in the entire state. A growing body of evidence had shown how racial biases throughout the medical system meant worse results for African Americans. And he knew the research - black patients were more responsive to, and more trustful of, black doctors. He decided after his trip that he'd start a temporary practice in Mississippi, and he rented an apartment deep in the Delta.

He fantasized about building a cardiovascular institute and recruiting a multidisciplinary team, from electrophysiologists to podiatrists. But as he researched what it would take, he found a major barrier. Medical specialists with student debt, who graduate owing a median of $200,000, generally could not benefit from federal loan forgiveness programs unless they got jobs at nonprofit or public facilities. Only a few types of private practice providers - primary care, dentists, psychiatrists - qualified for national loan forgiveness. The Delta needed many other physicians. Though Bolivar County was at the center of a diabetes epidemic, there wasn't a single diabetes specialist, an endocrinologist, within 100 miles.

Fakorede leased a windowless space in the Cleveland Medical Mall, a former shopping center that had been converted to doctors' offices. People came to him with heart complaints, but he also asked them to remove their socks. Their legs alarmed him. Their toes were black and their pulses weak. Their calves were cold and hairless. Some had wounds but didn't know it; diabetes had numbed their feet. Many had been misdiagnosed with arthritis or gout, but when Fakorede tested them, he found peripheral artery disease, in which clogged arteries in the legs limit the flow of blood.

This is what uncontrolled diabetes does to your body: Without enough insulin, or when your cells can't use it properly, sugar courses through your bloodstream. Plaque builds up faster in your vessels' walls, slowing the blood moving to your eyes and ankles and toes. Blindness can follow, or dead tissue. Many can't feel the pain of blood-starved limbs; the condition destroys nerves. If arteries close in the neck, it can cause a stroke. If they close in the heart, a heart attack. And if they close in the legs, gangrene.

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For decades, African Americans in the South struggled to find and afford health care. The American Medical Association excluded black doctors, as did its constituent societies. Some hospitals admitted black patients through back doors and housed them in hot, crowded basements. Many required them to bring their own sheets and spoons, or even nurses. Before federal law mandated emergency services for all, hospitals regularly turned away African Americans, some in their final moments of life.

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By the time Fakorede moved to the Delta, in 2015, the state had the nation's lowest number of physicians per capita. It had not expanded Medicaid to include the working poor. Across the country, 15% of African Americans were still uninsured, compared with 9% of white Americans. That year, Jennifer Smith, a professor at Florida A&M University College of Law, wrote in the National Lawyers Guild Review what Fakorede saw firsthand: "While the roots of unequal and inequitable health care for African Americans date back to the days of slavery, the modern mechanisms of discrimination in health care has shifted from legally sanctioned segregation to inferior or non-existent medical facilities due to market forces."

Fakorede understood that to reach patients, he needed referrals, so he met primary care providers at hospitals and clinics. He asked them to screen for vascular disease, measuring blood pressure at the ankle and the arm. Many didn't have the time; given the shortage of local physicians, some were seeing up to 70 patients a day. Others didn't know much about peripheral artery disease or why it was important to diagnose. Some were offended by Fakorede's requests.

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The brushoffs disturbed Fakorede, but when he dug deeper, he realized that the doctors weren't only overwhelmed; they had no guaranteed payment for this vascular screening. The Affordable Care Act mandates that insurers cover all primary care screenings that are recommended by the U.S. Preventive Services Task Force, an independent panel of preventive care experts. The group, though, had not recommended testing anybody without symptoms, even the people most likely to develop vascular disease - older adults with diabetes, for example, or smokers. (Up to 50% of people who have the disease are believed to be asymptomatic.) As specialists, cardiologists are reimbursed if they screen patients with risk factors. But by the time patients got to Fakorede, the disease was sometimes too far along to treat. Many already had a nonhealing wound, what's known as "end stage" peripheral artery disease, the last step before an amputation. General surgeons have a financial incentive to amputate; they don't get paid to operate if they recommend saving a limb. And many hospitals don't direct doctors to order angiograms, the most reliable imaging to show if and precisely where blood flow is blocked, giving the clearest picture of whether an amputation is necessary and how much needs to be cut. Insurers don't require the imaging, either. (A spokesperson for America's Health Insurance Plans, a leading industry trade association, said, "This is not an area where there is likely to be unnecessary surgery.") To Fakorede, this was like removing a woman's breast after she felt a lump, without first ordering a mammogram.

Nationwide, more than half of patients do not get an angiogram before amputation; in the Delta, Fakorede found that the vast majority of the amputees he treated had never had one. Now, he was determined to make sure that no one else lost a limb before getting the test. This wasn't a controversial view: The professional guidelines for vascular specialists - both surgeons and cardiologists - recommend imaging of the arteries before cutting, though many surgeons argue that in emergencies, noninvasive tests like ultrasounds are enough. Marie Gerhard-Herman, an associate professor of medicine at Harvard Medical School and a cardiologist at Brigham and Women's Hospital, chaired the committee on guidelines for the American College of Cardiology and the American Heart Association. She told me that angiography before amputation "was a view that some of us thought was so obvious that it didn't need to be stated." She added: "But then I saw that there were pockets of the country where no one was getting angiograms, and it seemed to be along racial and socioeconomic lines. It made me sick to my stomach."

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Patients didn't know about vascular disease, or why their legs throbbed or their feet blackened, so Fakorede went to church. The sales rep, Hampton, introduced him to pastors, and several times each month, he stood before a pulpit. He told the crowds that what was happening was an injustice, that they didn't need to accept it. He told them to get screened, and if any surgeon wanted to cut off their limbs, to get a second opinion. In the lofty Pilgrim Rest Baptist Church, in Greenville, he asked the congregation, "How many of you know someone or know of someone who's had an amputation?" Almost everyone raised their hands.

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In Bolivar, Fakorede had seen more than 10,000 cardiovascular patients from around the Delta. Dr. DeGail Hadley, a primary care provider in town, told me that before Fakorede arrived, he wasn't sure what was best to do for patients with rotting feet. "It was always a process of transferring the patients to Jackson or Memphis, which can be difficult." Both cities were two hours away. Now, Fakorede was performing about 500 angiograms annually in town. Last year, he published a paper in Cath Lab Digest describing an 88% decrease in major amputations at Bolivar Medical Center, from 56 to seven. (Fakorede did not provide me with all of his sources.) The hospital has different internal figures, which also reflect a significant decrease. Between 2014 and 2017, the hospital recorded that major amputations had fallen 75% - from 24 to six.